PMR Buzz Magazine_July 2022.pdf

PMR
BUZZ
Volume 3, Issue 3, July 2022
Contributors:
• Dr. Ravi Gaur, Associate Professor,
Department of PMR, AIIMS, Jodhpur.
• Dr. Navin BP, Assistant Professor,
Department of Neurorehabilitation,
NIMHANS, Bengaluru.
• Dr. Mahima Agrawal, Assistant Professor,
Department of PMR, JLN Medical
College, Ajmer.
• Dr. Harleen Uppal, Associate Professor,
Dept. of PMR, AIIMS, Nagpur.
• Dr. Vinay Goyal, Associate Professor,
Dept. of PMR, AIIPMR, Mumbai.
Editor & Contributor:
• Dr. Mrinal Joshi, Director & Professor
(PMR), Rehabilitation Research Centre,
SMS Medical College, Jaipur.

The association between hematologic parameters and intracranial
injuries in pediatric patients with traumatic brain injury.
Eser P, Corabay S, Ozmarasali AI, Ocakoglu G, Taskapilioglu MO
Brain Injury. 2022 May;36(6):740-9.
Objective
Analyzing the association between hematologic
parameters and abnormal cranial computerized
tomography (CT) findings after head trauma.
Material and Methods
A total of 287 children with isolated traumatic brain
injury (TBI) were divided into the ‘normal’ (NG), ‘linear
fracture’ (LFG) and ‘intraparenchymal injury’ groups
(IPG) based on head CT findings. Demographical /
clinical data and laboratory results were obtained from
medical records.
Results
The neutrophil-lymphocyte ratio was markedly higher
in the LFG (p = 0.010 and p = 0.016, respectively) and
IPG (p = 0.004 and p < 0.001, respectively) compared
with NG. Lower lymphocyte-monocyte ratio (p =
0.044) and higher red cell distribution width-platelet
ratio (RPR) (p = 0.030) were associated with
intraparenchymal injuries. Patients requiring
neurosurgical intervention had higher neutrophil-
lymphocyte ratio (p = 0.026) and RPR values (p = 0.031)
and lower platelet counts (p = 0.035). Lower levels of
erythrocytes (p = 0.005), hemoglobin (p = 0.003) and
hematocrit (p = 0.002) were associated with severe TBI
and unfavorable outcome (p = 0.012, p = 0.004 and p =
0.006, respectively).
Conclusions
Hematologic parameters are useful in predicting the
presence of abnormal cranial CT findings in children
with TBI in association with injury severity; surgery
need and clinical outcome.
1

2
Readmission following hospitalization for traumatic brain injury: a
nationwide study.
Kelly DJ, Thibault D, Tam D, Liu LJ, Cragg JJ, Willis AW, Crispo JA.
The Journal of Head Trauma Rehabilitation. 2022 May;37(3):E165-74.
Objective
To determine whether sociodemographic and clinical
factors were associated with nonelective readmission
within 30 days of hospitalization for traumatic brain
injury (TBI). Secondary objectives were to examine the
effects of TBI severity on readmission and characterize
primary reasons for readmission.
Setting
Hospitalized patients in the United States, using the
2014 Nationwide Readmission Database.
PARTICIPANTS
All patients hospitalized with a primary diagnosis of TBI
between January 1, 2014, and November 30, 2014. We
excluded patients (1) with a missing or invalid length of
stay or admission date, (2) who were nonresidents, and
3) who died during their index hospitalization.
Design
Observational study; cohort study.
Main Measures
Survey weighting was used to compute national
estimates of TBI hospitalization and nonelective 30-day
readmission. Associations between sociodemographic
and clinical factors with readmission were assessed
using unconditional logistic regression with and
without adjustment for suspected confounders.
Results
There were 135 542 individuals who were hospitalized
for TBI; 8.9% of patients were readmitted within 30
days of discharge. Age (strongest association for 65-74
years vs 18-24 years: adjusted odds ratio [AOR], 2.57;
95% CI: 2.02-3.27), documentation of a fall (AOR, 1.24;
95% CI: 1.13-1.35), and intentional self-injury (AOR,
3.13; 95% CI: 1.88-5.21) at the index admission were
positively associated with readmission. Conversely,
history of a motor vehicle (AOR, 0.69; 95% CI: 0.62-
0.78) or cycling (AOR, 0.56; 95% CI: 0.40-0.77)
accident was negatively associated with readmission.
Females were also less likely to be readmitted following
hospitalization for a TBI (AOR, 0.87; 95% CI: 0.82-
0.92).
Conclusions
Many sociodemographic and clinical factors were found
to be associated with acute readmission following
hospitalizations for TBI. Future studies are needed to
determine the extent to which readmissions following
TBI hospitalizations are preventable.

3
The minimal clinically important difference in Berg Balance Scale scores
among patients with early subacute stroke: a multicenter, retrospective,
observational study.
Tamura S, Miyata K, Kobayashi S, Takeda R, Iwamoto H.
Topics in Stroke Rehabilitation. 2022;29(6):423-9.
Background
Balance dysfunction is common in stroke patients. The
Berg Balance Scale (BBS) is useful for evaluating the
balance function of stroke patients, and it can estimate
the minimal clinically important difference (MCID) in
balance. BBS scores differ among stroke patients
depending on whether they require walking assistance.
The MCID should thus be estimated separately for
patients who require assistance and those who do not.
Objectives
To estimate the MCID of individuals who have had an
early subacute stroke and require a walking aid and
those who do not, to assist the clinical determination of
the effectiveness of therapy.
Methods
This was a retrospective clinical analysis of 80 early
subacute stroke patients. We estimated the MCID by
using the Functional Ambulation Categories (FAC) as
anchors for changes in BBS scores during a 1-month
period. The MCID was estimated based on a cutoff
score for separating the patients who achieved a FAC
change ≥1 point on receiver operator characteristic
curves. The area under the curve (AUC) was used to
measure the discrimination accuracy. The MCID was
estimated for the patients who needed walking
assistance and those who did not.
Results
The estimated MCID of BBS scores in the assisted-
walking group was 5 points and the AUC was 0.84 (p <
.01); the corresponding values in the unassisted-walking
group were 4 points and 0.62 (p = .26).
Conclusions
For early subacute stroke patients who require
assistance to walk, a 5-point improvement in the BBS
score is a useful indicator for reducing the amount of
assistance.

4
Early, Intensive, Lower Extremity Rehabilitation Shows Preliminary
Efficacy After Perinatal Stroke: Results of a Pilot Randomized Controlled
Trial.
Hurd C, Livingstone D, Brunton K, Smith A, Gorassini M, Watt MJ, Andersen J, Kirton A, Yang JF.
Neurorehabilitation and Neural Repair. 2022 Jun;36(6):360-70.
Background
Perinatal stroke injures motor regions of the brain,
compromising movement for life. Early, intensive,
active interventions for the upper extremity are
efficacious, but interventions for the lower extremity
remain understudied.
Objective
To determine the feasibility and potential efficacy of
ELEVATE—Engaging the Lower Extremity Via Active
Therapy Early—on gross motor function.
Methods
We conducted a single-blind, two-arm, randomized
controlled trial (RCT), with the Immediate Group
receiving the intervention while the Delay Group
served as a 3-month waitlist control. A separate cohort
living beyond commuting distance was trained by their
parents with guidance from physical therapists.
Participants were 8 months to 3 years old, with MRI-
confirmed perinatal ischemic stroke and early signs of
hemiparesis. The intervention was play-based, focused
on weight-bearing, balance and walking for 1 hour/day,
4 days/week for 12 weeks. The primary outcome was
the Gross Motor Function Measure-66 (GMFM-66).
Secondary outcomes included steps and gait analyses.
Final follow-up occurred at age 4.
Results
Thirty-four children participated (25 RCT, 9 Parent-
trained). The improvement in GMFM-66 over 12 weeks
was greater for the Immediate than the Delay Group in
the RCT (average change 3.4 units higher) and greater
in younger children. Average step counts reached
1370-3750 steps/session in the last week of training for
all children. Parent-trained children also improved but
with greater variability.
Conclusions
Early, activity-intensive lower extremity therapy for
young children with perinatal stroke is feasible and
improves gross motor function in the short term.
Longer term improvement may require additional
bouts of intervention.

5
Concomitant Detrusor and External Urethral Sphincter Botulinum
Toxin-a Injections in Male Spinal Cord Injury Patients with Detrusor
Overactivity and Detrusor Sphincter Dyssynergia.
Huang, Y.-H., & Chen, S.-L. (2022).
Journal of Rehabilitation Medicine, 54, jrm00264.
Objective
To investigate the effects of concomitant injections of
botulinum toxin-A (BoNT-A) into the detrusor and
external urethral sphincter muscles in suprasacral
spinal cord injured patients with detrusor overactivity
and detrusor sphincter dyssynergia.
Design
An open treatment trial with pre- and posttreatment
evaluations.
Subjects
Male suprasacral spinal cord injury patients (n = 20)
with neurogenic detrusor overactivity and detrusor
sphincter dyssynergia who emptied their bladder by
reflex voiding and were unwilling to increase the
frequency of intermittent catheterization.
Methods
Cystoscopic guidance of 200 U BoNT-A injections into
the detrusor muscle and 100 U into external urethral
sphincter muscles were applied. The urodynamic
parameters, voiding diaries and quality of life scores
using Urinary Distress Inventory, Short Form (UDI-6)
and Incontinence Impact Questionnaire, Short Form
(IIQ-7) were compared.
Results
All participants experienced a significant mean
reduction in maximal detrusor pressure and maximal
urethral pressure profile, and a mean significant
increase in maximal cystometric bladder capacity 12
weeks after concomitant injections. Bladder diaries
demonstrated persistently increased spontaneous
voided volume, but no increase in post-void residual
ratio, daily clean intermittent catheterization (CIC)
frequency and diaper pad use from baseline to 24
weeks. UDI-6 scores were significantly improved at 4
and 12 weeks and IIQ-7 scores improved only at 12
weeks.
Conclusion
Concomitant detrusor and external urethral sphincter
BoNT-A injections may decrease detrusor and urethral
pressure without increasing postvoid residual ratio and
diaper pad use. For spinal cord injury patients with
neurogenic detrusor overactivity and detrusor
sphincter dyssynergia who are unwilling, or for whom it
is inconvenient, to increase CIC frequency and who
want to preserve spontaneous voiding, this treatment
may provide an optional alternative.

6
Association of Physical Activity with Incidence of Dementia is Attenuated
by Air Pollution.
Raichlen DA, Furlong M, Klimentidis YC, Sayre MK, Parra KL, Bharadwaj PK, Wilcox RR, Alexander GE.
Med Sci Sports Exerc. 2022 Jul 1;54(7):1131-1138.
Introduction
Physical activity (PA) is recognized as one of the key
lifestyle behaviors that reduces risk of developing
dementia late in life. However, PA also leads to
increased respiration, and in areas with high levels of air
pollution, PA may increase exposure to pollutants
linked with higher risk of developing dementia. Here,
we investigate whether air pollution attenuates the
association between PA and dementia risk.
Methods
This prospective cohort study included 35,562 adults
60 yrs and older from the UK Biobank. Average
acceleration magnitude (ACC ave ) from wrist-worn
accelerometers was used to assess PA levels. Air
pollution levels (NO, NO 2 , PM 10 , PM 2.5 , PM 2.5–10
, and PM 2.5 absorbance ) were estimated with land use
regression methods. Incident all-cause dementia was
derived from inpatient hospital records and death
registry data.
Results
In adjusted models, ACC ave was associated with
reduced risk of developing dementia (HR = 0.71, 95%
confidence interval [CI] = 0.60–0.83), whereas air
pollution variables were not associated with dementia
risk. There were significant interactions between ACC
ave and PM 2.5 (HR interaction = 1.33, 95% CI =
1.13–1.57) and PM 2.5 absorbance (HR interaction =
1.24, 95% CI = 1.07–1.45) on incident dementia. At the
lowest tertiles of pollution, ACC ave was associated
with reduced risk of incident dementia (HR PM 2.5 =
0.66, 95% CI = 0.49–0.91; HR PM 2.5 absorbance =
0.60, 95% CI = 0.44–0.81). At the highest tertiles of
these pollutants, there was no significant association of
ACC ave with incident dementia (HR PM 2.5 = 0.88,
95% CI = 0.68–1.14; HR PM 2.5 absorbance = 0.79, 95%
CI = 0.60–1.04).
Conclusions
PA is associated with reduced risk of developing all-
cause dementia. However, exposure to even moderate
levels of air pollution attenuates the benefits of PA on
risk of dementia.

7
A Novel Pivot Ankle/foot Prosthesis Reduces Sound Side Loading and Risk
for Osteoarthritis: A Pragmatic Randomized Controlled Trial.
Runciman P, Cockcroft J, Derman W.
Prosthet Orthot Int. 2022 Jun 1;46(3):258-266.
Background
Individuals with unilateral transtibial amputation are at
risk of abnormal mechanical joint loading and
development of osteoarthritis on sound side joint
structures.
Objectives
This study describes the spatiotemporal and kinetic and
kinematic parameters related to osteoarthritis in
participants while using (A) a solid-ankle cushioned-
heel prosthesis (SACH), (B) a conventional energy
storage and return (ESAR) foot prosthesis, and (C) a
novel ESAR (N-ESAR) foot prosthesis.
Study design
A pragmatic randomized controlled trial.
Methods
K3-K4 ambulators used three feet in a 2-week
randomized cross-over order. Kinetics of vertical
ground reaction forces (vGRFs) and 3D kinematics of
joint angles were integrated to provide normalized
parameters. Data were analyzed using one way and
mixed model Analysis of variance (ANOVAs) (p < 0.05)
and Cohen d statistic.
Results
Twenty participants, aged 40 ± 16 years with body mass
index of 24.7 ± 3.6 kg/m2, experienced minimal change
in the spatiotemporal parameters between feet.
Participants using the N-ESAR foot prosthesis
experienced reduced peak knee external adduction
moment (p = 0.030), peak vGRFs (p < 0.001), and peak
loading rate of vGRFs (p = 0.030). Peak knee flexion
moments only changed when using the solid-ankle
cushioned-heel prosthesis, in a positive direction (p =
0.014). Using the N-ESAR prosthesis also increased
peak distal shank power during late stance phase (p <
0.001).
Conclusions
A novel ankle/foot ESAR prosthesis reduces loading on
the sound side. With extended use of the N-ESAR foot
prosthesis, these findings may provide the prosthesis
user with improved outcomes related to sound side
loading and development of osteoarthritis.

8
Local vibration training improves the recovery of quadriceps strength in
early rehabilitation after anterior cruciate ligament reconstruction: A
feasibility randomised controlled trial.
Claire Coulondre, Robin Souron, Alexandre Rambaud, Étienne Dalmais, Loïc Espeit, Thomas Neri, Alban Pinaroli, Gilles Estour,
Guillaume Y. Millet, Thomas Rupp, Léonard Feasson, Pascal Edouard, Thomas Lapole.
Annals of Physical and Rehabilitation Medicine,Volume 65, Issue 4, 2022.
Background
After anterior cruciate ligament reconstruction
(ACLR), quadriceps strength must be maximized as
early as possible.
Objectives
We tested whether local vibration training (LVT)
during the early post-ACLR period (i.e., ∼10 weeks)
could improve strength recovery.
Methods
This was a multicentric, open, parallel-group,
randomised controlled trial. Thirty individuals
attending ACLR were randomised by use of a dedicated
Web application to 2 groups: vibration (standardised
rehabilitation plus LVT, n = 16) or control
(standardised rehabilitation alone, n = 14).
Experimenters, physiotherapists and participants were
not blinded. Both groups received 24 sessions of
standardised rehabilitation over ∼10 weeks. In
addition, the vibration group received 1 hour of
vibration applied to the relaxed quadriceps of the
injured leg at the end of each rehabilitation session. The
primary outcome — maximal isometric strength of
both injured and non-injured legs (i.e., allowing for limb
asymmetry measurement) — was evaluated before
ACLR (PRE) and after the 10-week rehabilitation
(POST).
Results
Seven participants were lost to follow-up, so data for
23 participants were used in the complete-case
analysis. For the injured leg, the mean (SD) decrease in
maximal strength from PRE to POST was significantly
lower for the vibration than control group (n = 11,
−16% [10] vs. n = 12, −30% [11]; P = 0.0045, Cohen's d
effect size = 1.33). Mean PRE–POST change in limb
symmetry was lower for the vibration than control
group (−19% [11] vs. −29% [13]) but not significantly (P
= 0.051, Cohen's d effect size = 0.85).
Conclusion
LVT improved strength recovery after ACLR. This
feasibility study suggests that LVT applied to relaxed
muscles is a promising modality of vibration therapy
that could be implemented early in ACLR.

9
Radial shock-wave therapy for frozen shoulder patients with type 2
diabetes mellitus: a pilot trial comparing two different energy levels.
Tul
̈ ay C.
̧ Saldiran, Pelin Yagzan, Ahmet c. AKGOl
̈ , Fatma K. Mutluay.
European Journal of physical and Rehabilitation Medicine 2022 June; 58(3): 412-22.
Background
Extracorporeal shock-wave therapy (ESWT) is highly
recommended for the management of orthopedic
shoulder pathologies. Yet, the clinical relevance of the
dose difference effect of radial ESWT approaches in the
management of frozen shoulder patients with type 2
diabetes mellitus remains uncertain.
Aim
The aim was to examine the short-term effects of
medium-and high-energy levels of radial ESWT
(rESWT) in the treatment of frozen shoulder patients
with type 2 diabetes mellitus.
Design
Prospective clinical pilot study.
Setting
This study was conducted in an outpatient clinic.
Population
Thirty-nine patients who had frozen shoulder
untreated for at least 3 months, diagnosed with type 2
diabetes mellitus for ≥3 years were included.
Methods
The patients were randomly allocated to receive either
high-energy rESWT (hrESWT), or medium-energy
rESWT (mrESWT) or placebo at 8 Hz twice a week for
six weeks. The primary outcome measure was pain,
evaluated by the Visual Analog Scale (VAS) Score.
Secondary outcome measures were function evaluated
by the Shoulder Pain and Disability Index (SPADI)
Score, and shoulder active range of motion (AROM).
The mechanical properties of the deltoid and trapezius
muscles were assessed using the MyotonPRO (Myoton
AS, Tallinn, Estonia).
Results
The mrESWT resulted in statistically significant
reductions in night pain at 6 weeks (ηp2=0.27,
P=0.003). Significantly improved function (SPADI
scores: -35.42±21.29 vs.-29.59±22.60; ηp2=0.39,
P˂0.001) was found in both hrESWT and mrESWT
group by 6 weeks. Significantly higher mean shoulder
AROM values were recorded for external rotation
(ηp2=0.53, P<0.001), and internal rotation (ηp2=0.21,
P=0.020), in the hrESWT group at the 6th week. A
significantly improved resting tone (ηp2=0.58) and
stiffness of deltoid muscle (ηp2=0.62) were found in
the mrESWT group (P<0.001). The trapezius muscle
resting tone reduced with hrESWT (ηp2=0.17,
P=0.033).
Conclusions
Regardless of the energy levels, rESWT appears to be
an effective therapeutic intervention for frozen
shoulder patients with type 2 diabetes mellitus in the
short-term results.
Clinical rehabilitation impact
Our results suggest that this rESWT can be a useful
strategy for the rehabilitation of frozen shoulder
patients with type 2 diabetes mellitus. This is the first
study on dose difference effectiveness in terms of the
clinical significance of rESWT which is key to transfer
research evidence into practice.

10
Guideline for the management of neurogenic bowel dysfunction in spinal
cord injury/disease.
Kurze, I., Geng, V. & Böthig, R.
Spinal Cord 2022; 60, 435–443 (2022).
Introduction
Almost all people with spinal cord injury/disease
(SCI/D) suffer from neurogenic bowel dysfunction
(NBD), with a considerable impact on quality of life.
The Association of the Scientific Medical Societies in
Germany (AWMF e.V.) guideline for NBD in SCI/D
aims to provide practice-oriented support for the care
of patients with NBD resulting from congenital or
aquired SCI/D. The guideline describes the diagnosis
and bowel management of NBD in people with SCI/D.
Thus, treatment processes in acute medical care and
rehabilitation as well as for lifelong aftercare are
presented.
Methods
The present guideline was developed under the
leadership of the German-speaking Medical Society for
Paraplegiology in a multiprofessional interdisciplinary
guideline team. To exceed the level of expert
recommendations, consensus was reached within the
framework of a structured nominal group process in
defined steps under neutral moderation considering
the criteria of the German guideline development
instrument (DELBI).
Results
Individual bowel management must be developed on
the basis of an adequate diagnosis and considering the
different lesion types. Due to the multifactorial
influenceability of the intestine and the individual
neurological deficit, a simple to-do checklist is not
effective. Various and complex bowel management
programmes are the basis of the treatment of NBD.
Conclusions
Guidelines can only be successful in so far as they are
applied in everyday life. Of course, the selection and
application of the measures described must always take
into consideration the individual situation of the person
concerned, and the correct application is always a
prerequisite for success.

11
Accurate Prediction of Persistent Upper Extremity Impairment in
Patients with Ischemic Stroke.
Havenon et al.
Arch Phys Med Rehabil 2022; 103(5); 964-69.
Objective
To develop a simple and effective risk score for
predicting which stroke patients will have persistent
impairment of upper extremity motor function at 90
days.
Design
Post hoc analysis of clinical trial patients hospitalized
with acute ischemic stroke who were followed for 90
days to determine functional outcome.
Setting
Patient were hospitalized at facilities across the United
States.
Participants
We created a harmonized cohort of individual patients
(N=1653) from the NINDS tPA, ALIAS part 2, IMS-III,
DEFUSE 3, and FAST-MAG trials. We split the cohort
into balanced derivation and validation samples.
Interventions
Not applicable.
Main Outcome Measures
The primary outcome was persistent arm impairment,
defined as a National Institutes of Health Stroke Scale
(NIHSS) arm domain score of 2 to 4 at 90 days in
patients who had a 24-hour NIHSS arm score of 1 or
more. We used least absolute shrinkage and selection
operator regression to determine the elements of the
persistent upper extremity impairment (PUPPI) index,
which we validated as a predictive tool.
Results
We included 1653 patients (827 derivation, 826
validation), of whom 803 (48.6%) had persistent arm
impairment. The PUPPI index gives 1 point each for age
55 years or older and NIHSS values of worse arm (4),
worse leg (>2), facial palsy (3), and total NIHSS (≥10).
The optimal cutpoint for the PUPPI index was 3 or
greater, at which the area under the curve was greater
than 0.75 for the derivation and validation cohorts and
when using NIHSS values from either 24 hours or in a
subacute or discharge time window. Results were
similar across different levels of stroke severity.
Conclusion
The PUPPI index uses readily available information to
accurately predict persistent upper extremity motor
impairment at 90 days poststroke. The PUPPI index can
be administered in minutes and could be used as
inclusion criterion in recovery-related clinical trials or,
with additional development, as a prognostic tool for
patients, caregivers, and clinicians.

12
Rehabilitation definition for research purposes. A global stakeholders’
initiative by Cochrane Rehabilitation.
Stefano NEGRINI, Melissa SELB, Carlotte KIEKENS Alex TODHUNTER-BROWN, Chiara ARIENTI, Gerold STUCKI.
European Journal of Physical and Rehabilitation Medicine 2022 June;58(3):333-41.
Since its foundation, Cochrane Rehabilitation has faced
challenges with rehabilitation definitions because
existing definitions did not indicate what rehabilitation
includes and what it excludes. We aimed to develop a
comprehensive and shared rehabilitation definition for
research purposes to: 1) support the conduct of
primary studies and systematic reviews, and 2) identify
relevant systematic reviews for knowledge translation
purposes. We performed a multimodal study including
seven preliminary research and discussion papers, four
Consensus Meetings and three Delphi rounds with 80
rehabilitation stakeholders. The Delphi Study aimed to
obtain agreement, refine and complete the items
composing the definition and meanings of
rehabilitation. These stakeholders covered 5
continents, representing 11 global and continental
rehabilitation organizations, 11 scientific journals, 4
Cochrane Networks and 3 Cochrane Groups, and
included invited experts, and representatives of low
middle-income countries (LMICs) and consumers. We
had a 70% to 82.5% response rate to the three Delphi
rounds, during which participants responded to all
items (100%) and provided relevant comments (range
5.5-50% per item). This participation led to several
refinements to the rehabilitation definition through
three preliminary versions, and the final items reached
an agreement between 88.9% and 100%. We
structured the definition using the PICO (Population,
Intervention, Comparison, Outcome) framework. We
concluded that “In a health care context,” rehabilitation
is defined as a “multimodal, person-centered,
collaborative process” (Intervention-general),
including interventions targeting a person’s “capacity
(by addressing body structures, functions, and
activities/participation) and/or contextual factors
related to performance” (Intervention-specific) with
the goal of “optimizing” the “functioning” (Outcome)
of “persons with health conditions currently
experiencing disability or likely to experience disability,
or persons with disability” (Population). Rehabilitation
requires that all the items of the definition are satisfied.
We defined a “rehabilitation intervention” as “any
intervention provided within the rehabilitation
process.” We developed a rehabilitation definition for
research purposes achieving a broad agreement with
global stakeholders. This definition provides explicit
criteria to define rehabilitation. Using the proposed
definition will improve rehabilitation research by
standardizing the description of interventions. Our
definition may require revision in the future, as further
research enhances understanding and communication
of the essence and complexity of rehabilitation.
Key words
Rehabilitation; Evidence-based medicine; Clinical trial

13
Prognostic value of balance performance for improvements of
community ambulation among stroke patients: a cohort study.
Francesc MEDINA-MIRAPEIX, M. José CRISOSTOMO, Rodrigo MARTÍN SAN AGUSTÍN, M. Piedad SÁNCHEZ-MARTÍNEZ.
European Journal of Physical and Rehabilitation Medicine 2022 April;58(2):171-8.
Background
Despite the positive impact of improving the level of
community ambulation among stroke patients, little
prognostic research has focused on this indicator.
Aim
To investigate the prognostic value of the side-by-side,
semi-tandem, and tandem standing balance positions
and the five-sit-stand (5STS) test for discriminating
patients undergoing physical rehabilitation who
improve level of functional ambulation and predicting
transition time.
Design
A cohort study with assessments repeated monthly
until discharge for classifying patients in a community
ambulation class.
Setting
A neurological rehabilitation unit of a hospital in Spain.
Population
A consecutive sample of 109 stroke patients (68.5±12.0
years) was screened and included within four months
post stroke. Of them no one refused, 3 died, and 5 were
lost earlier to transition or discharge.
Methods
Balance tests, the 5STS and gait speed were measured
at the center at baseline and monthly until discarge.
Transition from household or limited community
ambulation to a higher ambulatory capacity or class.
Area under the curve (AUC) were used to compare
discriminative abilities of the tests and Cox regression
analysis to evaluate the association between the tests
and time of transition.
Results
For household non-ambulators, the semi-tandem was
the best discriminative test (AUC=0.850) and the three
balance tests showed an association with time to
transition. Among the limited community ambulators,
the 5STS test also revealed discriminative ability (AUC:
0.822 [0.63-1.00]), with a good prognostic cut-off (14.8
seconds) and association with time to transition
(Hazard Ratio: 1.22; 95%CI: 1.05-1.43).
Conclusions
Semi-tandem and the 5STS tests can discriminate
patients who improve level of functional ambulation
and predict transition times within three months in
non-ambulators and limited community ambulation
patients, respectively.

14
Quality improvement project of a closed catheter system to reduce
catheter-associated urinary tract infections during acute inpatient
rehabilitation using stepped-wedge design.
1 1 1 1 2 3
Argyrios Stampas , Jason Hua , Heather Naumann , Claudia I Martinez , DeAnn Roberts , Claudia Pedroza .
The Journal of International Society of Physical and Rehabilitation Medicine.2022;Vol.5(2);69-74.
Objective
To investigate if an indwelling catheter with a one-way
valve (BioFlo® [BF]) reduces the incidence of catheter-
associated urinary tract infections (CAUTIs).
Methods
Prospective quality improvement project. Design:
Stepped-wedge nursing unit enrollment in acute
inpatient rehabilitation facility (IRF) was conducted
over 9 months. All patients admitted to IRF that used an
indwelling catheter at any time during admission were
included, with all days and types of voiding methods
collected when in the study period. Comparisons were
between BF versus usual care (Foley catheter), with
incidence of CAUTI as the primary outcome measure.
Results
There were 227 patients: 21 using BF only, 146 using
Foley only, and 60 using both. This resulted in 206 Foley
users and 81 BF users. The BF group had a greater
percentage of patients with CAUTI compared to the
Foley group (30% vs. 17%, P = 0.021). Using generalized
linear modeling and adjusting for confounders revealed
an 89% increased risk of CAUTI in the BF group
compared to the Foley group (odds ratio: 1.89, P =
0.033). Bayesian analysis determined that the
probability of BF increasing the rate of CAUTI was 96%
(95% credible interval: 0.95–2.7).
Conclusions
Maintaining a closed catheter system with BF does not
reduce the rates of CAUTIs during acute inpatient
rehabilitation.

15
Comparative Efficacy of Rotator Interval Versus Posterior Capsule
Approach Intraarticular Corticosteroid Injections for Primary Frozen
Shoulder: A Single-blind, Randomized Trial.
Pain Physician 2022: 25:313-321.
Background
Intraarticular (IA) corticosteroid injection is commonly
performed in patients with primary frozen shoulder
(PFS). However, the best administration site remains
controversial.
Objectives
To compare the efficacy of rotator interval (RI) vs
posterior capsule (PC) approach for ultrasound-guided
corticosteroid injections into the glenohumeral joint of
patients with PFS.
Study Design
A randomized, exploratory, prospective study.
Setting
A single fellowship training institution in Daegu,
Republic of Korea.
Methods
This study was approved by the Institutional Review
Board (2019-04-047-001). Ninety patients with PFS
were randomly assigned to either RI approach (RI
group, n = 43) or PC approach (PC group, n = 45) for
ultrasound-guided IA corticosteroid injection.
Fluoroscopic images to assess the accuracy of the
injection were obtained immediately after injection by a
shoulder specialist. Visual Analog Scale for pain, the
American Shoulder and Elbow Surgeons score, the
subjective shoulder value, and range of motion (ROM)
were used to assess clinical outcomes for all patients at
the time of presentation, and at 3, 6, and 12 weeks after
injection.
Results
The accuracy of injection was 76.7% (33/43) and 93.3%
(42/45) in the RI and PC groups, respectively; the
between-group difference was statistically significant (P
= .028). Significant improvements were observed in
both groups in terms of all clinical scores and ROMs
throughout follow-up until 12 weeks after the injection
(all P < .001). At 12 weeks, better improvements in
forward flexion and abduction (P = .049 and .044) were
observed in the RI group than in the PC group. No
adverse effect related to injection was observed in
either group.
Limitations
This study had no control group receiving placebo
injections and limited follow-up time.
Conclusions
Both groups showed significant pain reduction and
functional improvement until 12 weeks after injection.
Although no significant differences were observed in
pain and functional scores between the 2 groups, the RI
group showed better improvement of ROM than the
PC group. These results indicate that the RI and
anterior structures are a major site in the pathogenesis
and treatment target of PFS.

16
A new technique for controlling intractable pain in lumbar spinal stenosis
using steroid injection to ligamentum flavum: A case series.
Rho JH, Yoon CD, Kim G, Kang HY.
Pain Pract. 2022 May 31. doi: 10.1111/papr.13133. Epub ahead of print.
Background
Lumbar spinal stenosis is a common degenerative
disease that causes low back and lower-extremity pain
that increases with age. The treatment of lumbar spinal
stenosis is either conservative or surgical. ESI is a
commonly performed conservative treatment, but
evidence of its effectiveness in lumbar spinal stenosis is
limited.
Case series
We encountered the three patients with back pain and
claudication due to lumbar spinal stenosis, which could
not be controlled by conservative therapy including
ESIs. Trimacinolone acetonide was injected into the
patients' ligamentum flavum. All patients experienced
dramatic improvement in their symptoms.
Conclusions
Trimacinolone acetonide injection into the ligamentum
flavum may be effective for lumbar spinal stenosis that
does not improve with ESIs.

Supports patients initiatives programs
In Cerebral Palsy,
In Spasticity,
Abridged Prescribing Information (BACLOF)
Active Ingredient: each tablet of BACLOF contains: baclofen 10, 25 mg, BACLOF liquid contains baclofen 5mg/5ml, 100 ml bottle. Indication: treatment of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms and concomitant
pain, clonus, and muscular rigidity. Dosage: Tablets: Initiate with a low dosage, preferably in divided doses, administered orally. Increase gradually based on clinical response and tolerability. The maximum dosage is 80 mg daily (20 mg four times a day). When
discontinuing, reduce the dosage slowly. Liquid: adults: One 5ml spoonful (5mg) 3 times a day for 3 days; Two 5ml spoonfuls (10mg) 3 times a day for 3 days; Three 5ml spoonfuls (15mg) 3 times a day for 3 days; Four 5ml spoonfuls (20mg) 3 times a day for 3
days.Elderly:Smalldosesshouldbeusedatthe start oftreatment, the dosebeing titrated graduallyagainst the response,under carefulsupervision.Paediatric population(0to<18years):Adosageof0.75-2mg/kg bodyweight shouldbeused.In children over
ten years of age, however a maximum daily dosage of 2.5mg/kg body weight may be given. Treatment is usually started with half a 5ml spoonful (2.5mg) given 4 times daily. The recommended daily dosages for maintenance therapy are as: 12 months – 2
years: Two to four 5ml spoonfuls (10-20mg), 2 years – 6 years: Four to six 5ml spoonfuls (20-30mg); 6 years – 10 years: Six to twelve 5ml spoonfuls (30-60mg). Contraindications: hypersensitivity to baclofen or any component of this product. Warning and
precautions: Abrupt discontinuation of baclofen has resulted in serious adverse reactions including death; therefore, reduce the dosage slowly when baclofen is discontinued. Neonatal withdrawal symptoms can occur; gradually reduce the dosage and
discontinue baclofen before delivery. Baclofen can cause drowsiness and sedation. Patients should avoid the operation of automobiles or other dangerous machinery until they know how the drug affects them. Advise patients that the central nervous system
effects of baclofen may be additive to those of alcohol and other CNS depressants. Baclofen can cause exacerbation of the following: psychotic disorders, schizophrenia, or confusional states; autonomic dysreflexia; epilepsy. Use with caution in patients with
these condition. Pregnancy & Lactation: Pregnancy: Based on animal data, may cause fetal harm. At recommended oral doses, baclofen is present in human milk. There are no human data on the effects of baclofen on milk production and on breastfed infant.
Interaction: CNS depressants like benzodiazepines, antihistamine, antipsychotic, and alcohol etc., may cause increased sedative effects. Morphine (epidural) may cause hypotension and dyspnea. Laboratory Test Interactions may cause false elevation of
AST (aspartate aminotransferase), alkaline phosphatase, or blood glucose. Adverse reactions: most common drowsiness, dizziness, and weakness. Overdose: Symptoms: Patients may present in coma or with progressive drowsiness, lightheadedness,
dizziness, somnolence, accommodation disorders, respiratory depression, seizures, or hypotonia progressing to loss of consciousness. Treatment: includes gastric decontamination, maintaining an adequate airway and respirations. (Prepared on 23rd Feb
2020. It is recommended to refer full prescribing information before prescription. For further medical information, please write to: Intas Pharmaceuticals Ltd., Corporate House, Near Sola Bridge, SG highway, Thaltej, Ahmedabad-380054, Gujarat, India.
productqueries@intaspharma.com.)
Abridged Prescribing Information (BACLOF LIQUID)
Active Ingredient: each tablet of BACLOF contains: baclofen 10, 25 mg, BACLOF liquid contains baclofen 5mg/5ml, 100 ml bottle. Indication: treatment of spasticity resulting from multiple sclerosis, particularly for the relief of flexor spasms and concomitant
pain, clonus, and muscular rigidity. Dosage: Tablets: Initiate with a low dosage, preferably in divided doses, administered orally. Increase gradually based on clinical response and tolerability. The maximum dosage is 80 mg daily (20 mg four times a day). When
discontinuing, reduce the dosage slowly. Liquid: adults: One 5ml spoonful (5mg) 3 times a day for 3 days; Two 5ml spoonfuls (10mg) 3 times a day for 3 days; Three 5ml spoonfuls (15mg) 3 times a day for 3 days; Four 5ml spoonfuls (20mg) 3 times a day for 3
days.Elderly:Smalldosesshouldbeusedatthe start oftreatment, the dosebeing titrated graduallyagainst the response,under carefulsupervision.Paediatric population(0to<18years):Adosageof0.75-2mg/kg bodyweight shouldbeused.In children over
ten years of age, however a maximum daily dosage of 2.5mg/kg body weight may be given. Treatment is usually started with half a 5ml spoonful (2.5mg) given 4 times daily. The recommended daily dosages for maintenance therapy are as: 12 months – 2
years: Two to four 5ml spoonfuls (10-20mg), 2 years – 6 years: Four to six 5ml spoonfuls (20-30mg); 6 years – 10 years: Six to twelve 5ml spoonfuls (30-60mg). Contraindications: hypersensitivity to baclofen or any component of this product. Warning and
precautions: Abrupt discontinuation of baclofen has resulted in serious adverse reactions including death; therefore, reduce the dosage slowly when baclofen is discontinued. Neonatal withdrawal symptoms can occur; gradually reduce the dosage and
discontinue baclofen before delivery. Baclofen can cause drowsiness and sedation. Patients should avoid the operation of automobiles or other dangerous machinery until they know how the drug affects them. Advise patients that the central nervous system
effects of baclofen may be additive to those of alcohol and other CNS depressants. Baclofen can cause exacerbation of the following: psychotic disorders, schizophrenia, or confusional states; autonomic dysreflexia; epilepsy. Use with caution in patients with
these condition. Pregnancy & Lactation: Pregnancy: Based on animal data, may cause fetal harm. At recommended oral doses, baclofen is present in human milk. There are no human data on the effects of baclofen on milk production and on breastfed infant.
Interaction: CNS depressants like benzodiazepines, antihistamine, antipsychotic, and alcohol etc., may cause increased sedative effects. Morphine (epidural) may cause hypotension and dyspnea. Laboratory Test Interactions may cause false elevation of
AST (aspartate aminotransferase), alkaline phosphatase, or blood glucose. Adverse reactions: most common drowsiness, dizziness, and weakness. Overdose: Symptoms: Patients may present in coma or with progressive drowsiness, lightheadedness,
dizziness, somnolence, accommodation disorders, respiratory depression, seizures, or hypotonia progressing to loss of consciousness. Treatment: includes gastric decontamination, maintaining an adequate airway and respirations. (Prepared on 23rd Feb
2020. It is recommended to refer full prescribing information before prescription. For further medical information, please write to: Intas Pharmaceuticals Ltd., Corporate House, Near Sola Bridge, SG highway, Thaltej, Ahmedabad-380054, Gujarat, India.
productqueries@intaspharma.com.)
Disclaimer: The matter content in this infographic is solely for educational purposes only. It does not intend either directly or indirectly expressly or impliedly to promote, propagate, advertise or otherwise endorsing any particular product or brand. The matter content in this infographic does not make any
representation or warranties with respect to the efficacy, accuracy, usefulness or applicability, or fitness, or completeness for any particular purpose. The content has been created by editorial board of PMR buzz with an unconditional educational grant from Intas Pharmaceuticals Pvt. Ltd.. The creators of this
infographic hereby disclaim any and all liability to any party for any direct, indirect, implied, punitive, special, incidental or other consequential damages arising directly or indirectly from any use of this infographics, which is provided as is, and without warranties.
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